CONFERENCE REGISTRATION FORM

WELLNESS: BUILDING CAPACITY FOR TOMORROW’S OLDER ADULT

DATE: September 24-25, 2015

TIME:8:00 AM – 5:30 PM, Registration starts at 7:30 AM

LOCATION: Oklahoma State University-Tulsa, Tulsa, OK

WEB PAGE:

REGISTER ONLINE:

OBJECTIVES: Conference attendees are provided evidence-based information to enhance the knowledge and best practice of attendees.

TARGET AUDIENCE:Linking Gerontology and Geriatrics conferences and activities are designed for community members, health, social behavior, and human service professionals working with older adults.

OPEN TO THE PUBLIC.Participants may attend one or all sessions.

PARTICIPANT INFORMATION

To provide required information to funders and sponsors, please complete the entire registration form:

Title (Ms., Miss, Mrs., Mr., etc.) / ______
First Name: / ______
Last Name: / ______
Credentials: (Ex:MS,PhD, MD) / ______
Position: / ______
Organization: / ______
Address:Home or Work / ______
City: ______ / State: ______Zip Code: ______
Daytime Phone: / ______
Cellular Phone: / ______
Email: (please print clearly) / ______
Verify Email: (print clearly) / ______
Emergency Contact Name: / ______
Emergency Contact Phone NO.: / ______

National Health Service Corps Member Yes No

Ido not haveregular therapeutic contact with patients. If no, please move to the “profession question.”

I have regular therapeutic contact with patients. If so, please indicate the clinical sites in which you work.

For each location you select, please indicate the number of patient encounters you have in an average day.

Check all that apply:

Check all that apply:
Title /
# of patients
/ Title /
# of patients
Ambulatory Care Centers / Nursing Home Caregivers
Assisted Living / Nursing Home Administrators
Chronic & Acute Hospitals / Palliative Care
Home Care / Senior Centers
Hospice / Senior Housing
Telehealth
Extension Educator/Director
Other (Describe):

NOTE: To help us secure continued funding, attendance information is crucial for required reports to funders of the current event, such as OSU, Center for Family Resilience, Magellan,PTAC, and others.

What is your profession?(Check the best selection of M1 through M5)

Medical Assistant-M1
Long Term Care Administration / Clinical Laboratory Worker
Nutrition/Dietetics / EMT-Paramedic/First Responder
Occupational Therapy (OT) / Health Information Systems/
Physical Therapy (PT)
Respiratory Therapy Physician Assist/Associate Speech/Language Pathology / Data Analyst Radiologic Services Other, specify

What is your profession?(Check the best selection of M1 through M5) – Continued

Medicine-M2
MD / DO / Other Medicine
Allopathic Medicine / Family Medicine / Optometry
Family Medicine / Internal Medicine / Pharmacy
Internal Medicine / Geriatric Medicine / Public Health
Geriatric Medicine / Psychiatry / Other, specify
Psychiatry / Geriatric Psychiatry
Geriatric Psychiatry / Chiropractic
Chiropractic / Podiatry
Podiatry
Other, specify / Other, specify
Nursing-M3 / Dentistry-M4
CNS / Geriatric Dentistry
Home Health Aide / Dental Assistant
LPN/LVN / Dental Hygiene
PCA / General Dentistry
NP / Other, specify
RN and/or BSN
Registered Nurse Student Other, specify
Social Behavioral Professionals-M5
Pastoral Care / LMFT / Academic Faculty
Attorney / LPC / Extension Service/Related positions
Paralegal / LADC / Gerontologist
Law Enforcement / Counseling Psychologist / Geriatrician
Security / Social Work / Clinical Psychologist
Clinical Social Worker / Other, specify
Substance Abuse/Addictions Counseling

Age Group Less than 20 years old 20-29 years old 30-39 years old

40-49 years old 50-59 years old 60-69 years old

70 years or older

EQUIPMENT/SUPPLIES

I agree to return all loaned equipment, such as clickers, wraps, etc.

SIGNATURE: DATE:

EMPLOYMENT

What is your employment?(Check only the one that best applies of sections E1 to E4)

E1-Academia
Public Private
Administrator/Manager / Student
Academic Faculty / Resident
Clinical Faculty / Fellow
Other, specify / Other, specify
E2-Governmental Agencies/Organizations
City/County Health Department / Health Resources and Services Administration (HRSA)
Other City/County Government / National Institutes of Health (NIH)
Local DHS/DHHS / National Health Service Corp Site
State Health Department / Veteran’s Administration
Other State Government / Other Federal Government
Area Health Education Centers (AHEC) / Indian Health Service (IHS)
Centers for Disease Control (CDC)
Geriatric Education Centers (GEC) / Tribal Government/Health Service
Other, specify
E3-Health Care / E4-Other Employment Options
Ambulatory Practice Site / Community-Based Org/Non-Profit
Federally-Qualified Health Center / In-Service/Continuing Education Coordinator
Health Care for the Homeless / Unemployed/Community Member/Family Member
Hospital / Retired
Nursing Home/Assisted Care / Other, specify
Public Housing Primary Care
Health Care Practitioner
Other, specify

CONTINUING EDUCATION CREDIT (CEU)

Look for updates at:

SPECIAL MEAL REQUIREMENTS

Vegetarian Meal Requested

Food Allergies or Restrictions: Please Specify

Indicate any accommodations for persons with disabilities:

** REQUESTS FOR PERSONS WITH DISABILITIES OR FUNCTIONAL NEEDS

Accommodations on the basis of disabilities are available by calling Dr. Tammy Henderson at 405-744-8350 at least 6 weeks before the conference.

NOTE: Please be prepared to provide your parking information including the make, model, color, license plate, and state associated with your vehicle for issuing parking permit.

REGISTRATION FEES AND POLICIES

General SeniorsStudents

Early Bird Registration (Paid byAugust 1,2015) $35$25

General Registration (Paidbetween August 2to September 1, 2015) $55 $35

Onsite Registration – limited seats $85 $55

NOTES:

  • Lunch is included in the registration cost.
  • Documentation is required as proof of academic status and age.
  • Refund requests will not be accepted after August 15, 2015

PAYMENT

  1. To pay online, click here.
  1. To pay by purchase order or CVI, please callMrs. Rita Ryan, 405-744-5047
  1. To pay by check:
  • Make checks payable to OSU HDFS-LGG;
  • Please place OSU HDFS-LGG CONFERENCE in the comments section of the check; and
  • Mail checkand completed Registration form to the attentionof:

RitaRyan

233 Human Sciences

Oklahoma State University
Stillwater, OK 74078-6122

Telephone: 405-744-5047 or FAX: 405-744-6344

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